Role of corticosteroids in allergic diseases

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  • CYTOKONES PROFILE IN LONG-TERM USE OF CORTICOSTEROID INHALATION IN CHILDHOOD ASTHMA RECEIVING IMMUNOTHERAPY
  • Role of corticosteroids in allergic diseases

    1. 1. Role of Corticosteroids in AllergicDiseasesProf DR Dr Ariyanto Harsono SpA(K)Prof DR Dr Ariyanto Harsono SpA(K) 1
    2. 2. Factors of the occurrence ofAllergySeveral factors affect the occurrence of allergyare:• genetic• exposure to Allergens• Mucosal barrierProf DR Dr Ariyanto Harsono SpA(K) 2
    3. 3. 4 Sorts of AllergensProf DR Dr Ariyanto Harsono SpA(K)FruitsMilkEggsFishNuts3
    4. 4. AlergenAPC MHC-II Th0IL-12/ IL-1Th-2Th.1IL-1 IL-2, IFN-γB-CellIL-4IL-5SEL PLASMASEL MEMORIIL-6IL-10AMemory CellsProf DR Dr Ariyanto Harsono SpA(K)ACTIVAtion of IMUNOCOMPETENCE Cells byANTIGENS 4
    5. 5. BACTIVATION of STRUCTURALCELLSNature Rev Immunol 2003; 3: 867-78NeutrophilEosinophilProf DR Dr Ariyanto Harsono SpA(K)5
    6. 6. CMEDIATORS RELEASEProf DR Dr Ariyanto Harsono SpA(K) 6
    7. 7. Granule contents:Histamine,TNF-αProteases, HeparinLipid mediators:ProstaglandinsLeukotrienesCytokine production:Specifically IL-4, IL-13Prof DR Dr Ariyanto Harsono SpA(K) 7
    8. 8. D EFFECTS of MEDIATORS RELEASE to TARGET ORGANNature Rev Immunol 2004: 3:234-237Prof DR Dr Ariyanto Harsono SpA(K)Pada Kulit:-Urticaria-Dermatitis Atopika-Udema Quinke8
    9. 9. D EFECTS of MEDIATORS RELEASE to TARGET ORGANNature Rev Immunol 2004: 3:234-237Prof DR Dr Ariyanto Harsono SpA(K)Pada Paru:-Asma-Batuk kronik Berulang9
    10. 10. D EFECTS of MEDIATORS RELEASE to TARGET OrganNature Rev Immunol 2004: 3:234-237Prof DR Dr Ariyanto Harsono SpA(K)Pada Hidung:-Rinitis Alergika-Sinusitis10
    11. 11. DNature Rev Immunol 2004: 3:234-237Prof DR Dr Ariyanto Harsono SpA(K)Pada Mata:-Conjunctivitis vernalis11EFECTS of MEDIATORS RELEASE to TARGETORGAN
    12. 12. DNature Rev Immunol 2004: 3:234-237Prof DR Dr Ariyanto Harsono SpA(K)Pada vaskuler:-Anafilaksis12EFECTS of MEDIATORS RELEASE to TARGETORGAN
    13. 13. DNature Rev Immunol 2004: 3:234-237Prof DR Dr Ariyanto Harsono SpA(K)Pada GI:-Protein loosing enteropati-GI haemorrhage-Eosinophilic Gastroenteritis13EFECTS of MEDIATORS RELEASE to TARGETORGAN
    14. 14. CE SymptomsProf DR Dr Ariyanto Harsono SpA(K) 14Oral allergy syndrome
    15. 15. Prof DR Dr Ariyanto Harsono SpA(K) 15Atopic Dermatitis
    16. 16. Asthma
    17. 17. Prof DR Dr Ariyanto Harsono SpA(K)Prof DR Dr Ariyanto Harsono SpA(K)17Urticaria
    18. 18. Prof DR Dr Ariyanto Harsono SpA(K) 18Quinke’s oedem
    19. 19. Prof DR Dr Ariyanto Harsono SpA(K) 19Quinke’s oedem
    20. 20. Prof DR Dr Ariyanto Harsono SpA(K) 20Quinke’s oedem
    21. 21. Prof DR Dr Ariyanto Harsono SpA(K) 21HSP
    22. 22. Prof DR Dr Ariyanto Harsono SpA(K) 22Fixed Skin Eruption
    23. 23. Serum SicknessProf DR Dr Ariyanto Harsono SpA(K) 23
    24. 24. Steven Johnson SyndromeProf DR Dr Ariyanto Harsono SpA(K) 24
    25. 25. Toxic Epidermal NecrolysisProf DR Dr Ariyanto Harsono SpA(K) 25
    26. 26. Diagnosisanamnesisphysical examinationExamination Support:Skin testTotal IgESpecific IgEPrausnitz- Kustner TestElimination-Provocation TestProf DR Dr Ariyanto Harsono SpA(K) 26
    27. 27. ManagementGeneral Procedure: Find the Cause, avoidancePrimary preventionSecondary preventionTertiary preventionProf DR Dr Ariyanto Harsono SpA(K) 27
    28. 28. ManagementGeneral Procedure: Find the Cause avoidPrimary preventionSecondary preventionTertiary preventionProf DR Dr Ariyanto Harsono SpA(K) 28
    29. 29. Drugs and therapy used to treat allergies can bedivided into broad groups:• Drugs that block the activity of chemicals that are releasedin the body during allergic reactions - antihistamines andleukotriene antagonists;• Drugs which relax the constricted muscle around the airwaysof the lungs, or shrink congested tissue, or reverse theeffects of the chemicals released during allergic reactions -bronchodilators, decongestants and epinephrine; antiacetylchloline• Drugs that prevent the activation of cells that are involved inthe allergic reaction - anti-allergic agents;• Drugs which possess a more general action in reducinginflammation - corticosteroids;• Therapy which modifies the immune response - allergenimmunotherapy. Prof DR Dr Ariyanto Harsono SpA(K) 29
    30. 30. Drugs and therapy used to treat allergies can bedivided into broad groups:• Drugs that block the activity of chemicals that are releasedin the body during allergic reactions - antihistamines andleukotriene antagonists;• Drugs which relax the constricted muscle around the airwaysof the lungs, or shrink congested tissue, or reverse theeffects of the chemicals released during allergic reactions -bronchodilators, decongestants and epinephrine; antiacetylchloline• Drugs that prevent the activation of cells that are involved inthe allergic reaction - anti-allergic agents;• Drugs which possess a more general action in reducinginflammation - corticosteroids;• Therapy which modifies the immune response - allergenimmunotherapy. Prof DR Dr Ariyanto Harsono SpA(K) 30
    31. 31. Prof DR Dr Ariyanto Harsono SpA(K) 31
    32. 32. Molecular Mechanism of Cortico SteroidProf DR Dr Ariyanto Harsono SpA(K) 32
    33. 33. All Allergy Immunology Association agreedCortico steroid use in the treatment of allergies• Unless UrticariaProf DR Dr Ariyanto Harsono SpA(K) 33
    34. 34. Mild Moderate SevereMild to Moderate Potency Topical SteroidsPimecrolimusTacrolimusCyclosporine, mycophenolateLight treatmentProf DR Dr Ariyanto Harsono SpA(K) 34Treatment Strategy in ADEmolientDry skin Itching and/or early sign ofinflammationFlareIVIGOral Steroids
    35. 35. Prof DR Dr Ariyanto Harsono SpA(K) 35
    36. 36. Dermatologic Diseases• For control of severe or incapacitating allergicconditions (e.g., contact dermatitis, atopicdermatitis) intractable to adequate trials ofconventional treatment.Prof DR Dr Ariyanto Harsono SpA(K) 36
    37. 37. ARIA = Allergic Rhinitis and its Impact on Asthma.Bousquet et al. J Allergy Clin Immunol. 2001;108 (5 suppl):S147.ARIA Guidelines: Recommendationsfor Management of Allergic RhinitisMildintermittentModeratesevereintermittentMildpersistentModerateseverepersistentImmunotherapyAllergen and irritant avoidanceIntranasal decongestant (<10 days) or oral decongestantSecond-generation nonsedating H1 antihistamineLeukotriene receptor antagonistsLocal cromoneIntra-nasal steroid37Prof DR Dr Ariyanto Harsono SpAK
    38. 38. Prof DR Dr Ariyanto Harsono SpA(K) 38
    39. 39. Prof DR Dr Ariyanto Harsono SpA(K) 39
    40. 40. Prof. DR.Dr.Ariyanto Harsono SpA(K) 40Management of Anaphylaxis1. Primary treatment• Adrenaline 1:1000 with a dose of 0.001 ml / kg maximum: 0.3 mlsubcutaneously2. Complimentary MedicineIntended for complications:• Seizures: diazepam, phenobarbital• Spasm bronchi: Aminophylline 7 mg dissolved in 10-20 ml of 0.9% NaClfollowed 9 mg/kg/24 hours (divided into 3 doses)• b-2 agonist: Ventolin nebulizer3. Additional treatment• Antihistamines (H1 receptor antagonist): Benadril 2 mg / kg im continued3 mg/kg/24 hours orally (divided into 3 doses)• H-2 receptor antagonist: Simetidine• corticosteroids: Solukortef 4-7 mg/kg i.v.Followed with 4-7 mg/kg/24 hours oral (divided 3 dosis)
    41. 41. Prof DR Dr Ariyanto Harsono SpA(K) 41
    42. 42. GINA Asthma guidelineProf DR Dr Ariyanto Harsono SpA(K) 42
    43. 43. Prof DR Dr Ariyanto Harsono SpA(K) 43
    44. 44. Asthma• Used by oral inhalation for the long-term prevention of bronchospasm in patients withasthma.• Used orally for severe bronchial asthma intractable to conventional treatment.• Used orally for treatment of moderate to severe acute exacerbations of asthma (oralprednisone usually preferred). Speeds resolution of airflow obstruction and reduces rate ofrelapse.• Because onset of effects is delayed, do not use alone for emergency treatment.• Early systemic glucocorticoid therapy particularly important for asthma exacerbations ininfants and children.• In hospital management of an acute asthma exacerbation,systemic adjunctive glucocorticoids if response to oral inhalation therapy is not immediate, iforal corticosteroids were used as self-medication prior to hospitalization, or if the episode issevere.• For severe persistent asthma once initial control is achieved, high dosages of inhaledcorticosteroids are preferable to oral corticosteroids for maintenance because inhaledcorticosteroids have fewer systemic effects.Prof DR Dr Ariyanto Harsono SpA(K) 44
    45. 45. Prof DR Dr Ariyanto Harsono SpA(K) 45Conversion to Orally Inhaled Therapy in Patients ReceivingSystemic CorticosteroidsWhen switching from systemic corticosteroids to orally inhaled triamcinolone acetonide inpatients with asthma, asthma should be reasonably stable before initiating treatment withthe oral inhalation.Initially, administer the aerosol concurrently with the maintenance dosage of the systemiccorticosteroid. After about 1 week, gradually withdraw systemic corticosteroid by reducingthe daily or alternate daily dosage. Generally, decrease dosage in decrements of ≤2 mg oftriamcinolone acetonide after intervals of 1–2 weeks, depending on patient response.Death has occurred in some individuals in whom systemic corticosteroids were withdrawntoo rapidly.During withdrawal of oral therapy, symptoms of systemic corticosteroid withdrawal mayoccur, despite maintenance or even improvement in pulmonary function; continue oralinhalation therapy but monitor for objective signs of adrenal insufficiency. If evidence ofadrenal insufficiency occurs, increase systemic corticosteroid dosage temporarily andthen continue withdrawal more slowly.If exacerbations of asthma occur during oral inhalation therapy after systemiccorticosteroids have been withdrawn, administer short courses of systemic corticosteroids,then taper dosage as symptoms subside. Supplemental systemic corticosteroid therapymay also be required during periods of stress.
    46. 46. • Maintenance therapy with low doses of an orally inhaled corticosteroid ispreferred treatment for adults and children with mild persistent asthma (i.e.,patients with daytime symptoms of asthma more than twice weekly but less thanonce daily, and nocturnal symptoms of asthma more than twice per month).• A long-acting β2-agonist (e.g., formoterol, salmeterol) added to low- to medium-dose inhaled corticosteroids is the preferred therapy in patients with moderatepersistent asthma (i.e., patients with daily asthmatic symptoms); alternatively,may increase (e.g., double) maintenance dosage of inhaled corticosteroid withinmedium-dosage range in such patients.• Orally as an adjunct to other therapy to speed resolution of all but the mildestexacerbations of asthma when response to a short-acting inhaled β2-agonist is notprompt or sustained after 1 hour or in those who have a history of severeexacerbations.• Oral glucocorticoids with minimal mineralocorticoid activity and relatively shorthalf-life (e.g., prednisone, prednisolone, methylprednisolone) are preferred.• Do not use oral inhalation for the treatment of nonasthmatic bronchitis or forrelief of acute bronchospasm.Prof DR Dr Ariyanto Harsono SpA(K) 46
    47. 47. Dosage: Pediatric Patients• Base pediatric dosage on severity of the disease and patient response rather than on strictadherence to dosage indicated by age, body weight, or body surface area.• Usual Dosage• Oral• Some clinicians recommend 0.117–1.66 mg/kg daily or 3.3–50 mg/m2daily, administered in 4divided doses.• IM• Triamcinolone acetonide in children <6 years of age: Dosage not established; insufficientclinical experience to recommend use in this age group.• Triamcinolone acetonide in children 6–12 years of age: Initially, 40 mg depending on theseverity of the condition. Some clinicians recommend 0.03–0.2 mg/kg or 1–6.25 mg/m2at 1-to 7-day intervals.• Triamcinolone acetonide in children >12 years of age: Initially, 60 mg (using the 40-mg/mLsterile suspension). May administer additional doses of 20–100 mg (usually 40–80 mg) whensigns and symptoms recur; some clinicians recommend administration at 6-week intervals, ifpossible, to minimize HPA suppression.cSome patients may be well controlled on doses ≤20mg.Prof DR Dr Ariyanto Harsono SpA(K) 47
    48. 48. AsthmaOral Inhalation• Triamcinolone acetonide in children <6 years of age: manufacturer does notrecommended use in this age group.• Triamcinolone acetonide in children 6–12 years of age: Initially, 100 or 200 mcg (1or 2 sprays) 3 or 4 times daily (300–800 mcg total) or 200–400 mcg (2–4 sprays)twice daily (400–800 mcg total); adjust dosage according to patientresponse. Maximum dosage recommended by manufacturer is 1200 mcg (12sprays) daily; some experts state that higher dosages may be used in children withsevere persistent asthma.• Continually monitor patients for signs that indicate dosage adjustment isnecessary (e.g., remissions or exacerbations of disease and stress [surgery,infection, trauma]). (See Conversion to Orally Inhaled Therapy in PatientsReceiving Systemic Corticosteroids under Dosage and Administration.)Prof DR Dr Ariyanto Harsono SpA(K) 48
    49. 49. Prof DR Dr Ariyanto Harsono SpA(K) 49
    50. 50. Prof DR Dr Ariyanto Harsono SpA(K) 50
    51. 51. Prof Dr Ariyanto Harsono dr SpAKCURICULUM VITAETempat /tgl lahir : Kediri, 3- JuliAgama : IslamStatus Perkawinan: MenikahPendidikanS-1: Lulus Dokter : FK UNAIR, 1972S-2: Spesialis Anak : FK UNAIR, 1982S-3: Program Pascasarjana UNAIR, 2004Pendidikan tambahan : Sertifikat “Fellowship on Food Allergy”,Academisch Ziekenhuis Utrecht, Nederland, 1990-1991Jabatan sekarang : Guru Besar Ilmu Kesehatan Anak,Dep IKA FK UNAIR/RSU Dr.Soetomo, Surabaya.Konsultan Alergi/Imunologi: 1992Prof DR Dr Ariyanto Harsono SpA(K) 51
    52. 52. Thank YouProf DR Dr Ariyanto Harsono SpA(K)52

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